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1
The Identification, Assessment, and Treatment of PTSD at School
Stephen E. Brock, Ph.D., NCSPCalifornia State University, [email protected]
Melissa A. Reeves, Ph.D., NCSPWinthrop University, Rock Hill, [email protected]
National Association of School Psychologists (NSPA) & American Healthcare Institute (AHI) Critical Skills and Issues in School Psychology 2008 Summer Conference, July 30, 2008, Las Vegas, NV
2
Acknowledgements
Adapted from…Nickerson, A. B., Reeves, M. A., Brock, S. E., &
Jimerson, S. R. (in press). Assessing, identifying, and treating posttraumatic stress disorder at school. New York: Springer.
3
Preface
Trauma is a..“blow to the psyche that breaks through one’s defenses so suddenly and with such force that one cannot respond effectively.”
Kai EricksonIn the Wake of a Flood, 1979
4
Preface
PTSD necessarily involves exposure to a traumatic stressor.A traumatic stressor can generate initial stress reactions in just about anyone.However, not everyone exposed to these events develops PTSD.
Typically, the majority of exposed individuals recover and only a minority develop PTSD.
Among those who develop PTSD, significant impairments in daily functioning (including interpersonal and academic functioning) are observed.Developmentally younger individuals are more vulnerable to PTSD.
5
Preface
Prevalence among children and adolescentsGeneral Population
Trauma Exposure approximately 25%PTSD 6 to 10%
Urban PopulationsTrauma Exposure as high as 80%PTSD as high as 30%
Buka et al., 2001; Costello et al., 2002, Dyregory & Yule, 2006; Seedat et al., 2004
6
Preface
Range of Possible Traumatic Stress ReactionsNot Psychopathological (Common)
Initial Crisis ReactionsAcute Stress Disorder
Acute Post-Traumatic Stress DisorderChronic Post-Traumatic Stress Disorder
Psychopathological (Uncommon)
8
Preface
The role of the school-based mental health professional is to be …
able to recognize and screen for PTSD symptoms.aware of the fact PTSD may generate significant school functioning challenges.knowledgeable of effective treatments for PTSD and appropriate local referrals.cognizant of the limits of their training.
It is not necessarily to …diagnose PTSD.treat PTSD.
9
Workshop Outline
DSM-TR-IV Diagnostic CriteriaCausesConsequences
CognitiveEmotional and BehavioralAcademic
Initial Assessment (or Screening)Interventions
PreventionAcademicPsychologicalMedical
10
DSM-IV-TR Diagnostic Criteria for PTSD
An anxiety disorder that develops secondary to exposure (experiencing, witnessing, or learning about) to an “extreme traumatic stressor.”
An event that involves actual or threatened death or serious injury, or threat to ones physical integrity.
“The person’s response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior).”
(APA, 2000, p. 463)
11
DSM-IV-TR Diagnostic Criteria for PTSD
Traumatic events directly experienced may include, but are not limited to
Military combatViolent personal assaultBeing kidnappedBeing taken hostageTerrorist attackTortureNatural or manmade disastersSevere automobile accidentsBeing diagnosed with a life-threatening illness
Among children these events may includeDevelopmentally inappropriate sexual experiences
12
DSM-IV-TR Diagnostic Criteria for PTSD
Traumatic events that are witnessed may include, but are not limited to
Observing the serious injury/death of another person due toViolent assaultAccidentWarDisasters
Unexpectedly witnessing a dead body or body parts.
13
DSM-IV-TR Diagnostic Criteria for PTSD
Traumatic events that are experienced by others and that are subsequently learned about may include, but are not limited to
Violent personal assaultSerious accidentSerious injury experienced by a significant otherLearning about sudden unexpected death of a significant other
14
DSM-IV-TR Diagnostic Criteria for PTSD
Core Symptoms1. Persistent reexperiencing of the trauma.2. Persistent avoidance of stimuli associated with the trauma
and numbing of general responsiveness.3. Persistent symptoms of increased arousal.
Duration of the disturbance is more than one month.The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
APA, 2000
15
DSM-IV-TR Diagnostic Criteria for PTSD
Reexperiencing Symptoms1. Recurrent/intrusive distressing recollections.2. Recurrent distressing dreams.3. Acting/feeling as if the event were recurring.4. Psychological distress at exposure to cues that
symbolize/resemble the traumatic event.5. Physiological reactivity on exposure to cues that
symbolize/resemble the traumatic event.
APA, 2000
16
DSM-IV-TR Diagnostic Criteria for PTSD
Avoidance & Numbing Symptoms1. Avoids thoughts, feelings, or conversations.2. Avoids activities, places, or people.3. Inability to recall important aspects of the trauma.4. Diminished interest/participation in significant
activities.5. Feeling of detachment/estrangement.6. Restricted range of affect.7. Sense of a foreshortened future.
APA, 2000
17
DSM-IV-TR Diagnostic Criteria for PTSD
Increased Arousal Symptoms1. Difficulty falling or staying asleep.2. Irritability or outbursts of anger.3. Difficulty concentrating.4. Hypervigilance.5. Exaggerated startle response.
APA, 2000
18
DSM-IV-TR Diagnostic Criteria for PTSD
PTSD may be specified asAcuteChronicDelayed onset
APA, 2000
19
DSM-IV-TR Diagnostic Criteria for PTSD
Associated FeaturesSurvivor guiltImpaired social/interpersonal functioningAuditory hallucinations & paranoid ideationImpaired affect modulationsSelf-destructive and impulsive behaviorSomatic complaintsShame, despair, or hopelessnessHostilitySocial withdrawal
APA, 2000
20
DSM-IV-TR Diagnostic Criteria for PTSD
Associated Mental DisordersMajor Depressive DisorderSubstance-Related DisordersPanic Disorder AgoraphobiaObsessive-Compulsive DisorderGeneralized Anxiety DisorderSocial PhobiaSpecific PhobiaBipolar Disorder
APA, 2000
21
Workshop Outline
DSM-TR-IV Diagnostic CriteriaCausesConsequences
CognitiveEmotional and BehavioralAcademic
Initial Assessment (or Screening)Interventions
PreventionAcademicPsychologicalMedical
22
Causes of PTSD
InteractionsInternal Personal Vulnerabilities
Environmental Factors
Traumatic Event
PTSD
Nickerson et al., (in press)
23
Causes of PTSD
Traumatic Event VariablesType
PredictabilityAssaultive Interpersonal ViolenceFatalities
SeverityDurationIntensity
ExposurePhysical ProximityEmotional Proximity
Nickerson et al., (in press); Brock et al., (in preparation)
24
Causes of PTSD
Environmental FactorsParental ReactionsSocial SupportsHistory of Environmental Adversity/Traumatic StressFamily AtmosphereFamily Mental Health HistoryPoverty
Nickerson et al., (in press)
25
Causes of PTSD
Internal Personal VulnerabilitiesPsychological Factors
Crisis Perceptions and ReactionsMental IllnessDevelopmental LevelCoping StrategiesLocus of ControlSelf-esteem
Nickerson et al., (in press)
26
Causes of PTSD
Internal Personal Vulnerabilities (cont.)Genetic Factors
Family StudiesTwin StudiesCandidate Gene Studies
Nickerson et al., (in press)
27
Causes of PTSD
AmygdalaPituitary
HippocampusHypothalmus
Internal Personal Vulnerabilities (cont.)Neurobiological Factors
Nickerson et al., (in press)
28
Workshop Outline
DSM-TR-IV Diagnostic CriteriaCausesConsequences
CognitiveEmotional and BehavioralAcademic
Initial Assessment (or Screening)Interventions
PreventionAcademicPsychologicalMedical
29
Consequences of PTSD
Affects on cognitive functioning1. Motivation and persistence in academic tasks2. Development of short- and long-term goals3. Sequential memory4. Ordinal positioning5. Procedural memory6. Attention
30
Consequences of PTSD
Executive functioningEverything you think about has an emotional contextYou must emotionally engage students, learning doesn’t occur without positive emotional engagementWhen in an emotional state, frontal lobes are “off-line”You have input and output
Between input and output, organization needs to take placeHave to have organization of input to get output
Executive functioning is the conductor
31
Consequences of PTSD
Executive functioning difficultiesShould not be attributed to negative personal characteristics such as laziness, lack of motivation, apathy, irresponsibility, or obstinance
State problems in clear behavioral terms that indicate a behavior that can be changed.Intervention focuses on promoting positive, specific behavior change(s).
32
Consequences of PTSD
Emotional and behavioral consequences depends upon
Chronological ageDevelopmental stageWhether/not death involvedProximity to eventSupport System
33
Consequences of PTSD
Emotional and behavioral consequences occurring across age groups:1. Regression to childish/dependent behavior2. Fears/anxieties3. Changes in eating patterns4. Changes in sleeping patterns5. Gender differences6. School problems7. Disciplinary Referrals8. Freezing9. Dissociation
34
Consequences of PTSD
Conditions Co-morbid with Child PTSDAD/HDDepressionObsessive/Compulsive DisorderOppositional/Defiant DisorderAnxiety DisorderConduct Disorder
35
Consequences of PTSD
Academic1. Cognitive2. Academic achievement3. Academic performance4. Grade retention5. Adult outcome6. School behavior
36
Consequences of PTSD
PTSD & LD Childhood trauma creates difficulty with:
Focus (Traweek, 2006)
Social functioning (Rucklidge, 2006)
Decline in academic performance (Kruczek, 2006; Gahen, 2005)
Outbursts of anger, hyperactivity, impulsivity (Glod & Teicher, 1996)
All are symptoms often associated with LD
37
Consequences of PTSD
Developmental considerations: PreschoolersReactions not as clearly connected to the crisis event as observed among older students.Reactions tend to be expressed nonverbally.Given equal levels of distress and impairment, may not display as many PTSD symptoms as older children.Temporary loss of recently achieved developmental milestones.Trauma related play.
American Psychiatric Association, 2000; Berkowitz, 2003; Cook-Cottone, 2004; Dulmus, 2003; Joshi & Lewin, 2004; National Institute of Mental Health, 2001; Yorbik et al., 2004 )
38
Consequences of PTSD
Developmental considerations: School-age childrenReactions tend to be more directly connected to crisis event.Event specific fears may be displayed.Reactions are often expressed behaviorally.Feelings associated with the traumatic stress are often expressed via physical symptoms.Trauma related play (becomes more complex and elaborate).Repetitive verbal descriptions of the event.Problems paying attention.
American Psychiatric Association, 2000; Berkowitz, 2003; Cook-Cottone, 2004; Dulmus, 2003; Joshi & Lewin, 2004; National Institute of Mental Health, 2001; Yorbik et al., 2004 )
39
Consequences of PTSDDevelopmental considerations: Preadolescents and adolescents
More adult like reactionsSense of foreshortened futureOppositional/aggressive behaviors to regain a sense of controlSchool avoidanceSelf-injurious behavior and thinkingRevenge fantasiesSubstance abuseLearning problems
American Psychiatric Association, 2000; Berkowitz, 2003; Cook-Cottone, 2004; Dulmus, 2003; Joshi & Lewin, 2004; National Institute of Mental Health, 2001; Yorbik et al., 2004 )
40
Workshop Outline
DSM-TR-IV Diagnostic CriteriaCausesConsequences
CognitiveEmotional and BehavioralAcademic
Initial Assessment (or Screening)Interventions
PreventionAcademicPsychologicalMedical
41
Initial Assessment of PTSD
Crisis Event Type*a) Human Caused (vs. Natural)b) Intentional (vs. Accidental)c) Fatalities
*Risk factors that increase the probability of psychological trauma and, as such, should result in increased vigilance for psychological trauma warning signs.
Brock (2006); Brock et al. (in preparation)
42
Initial Assessment of PTSD
Crisis Exposure*a) Physical proximity
Intensity of crisis experienceb) Emotional proximity
*Risk factors that increase the probability of psychological trauma and, as such, should result in increased vigilance for psychological trauma warning signs.
Brock (2006); Brock et al. (in preparation)
43
Initial Assessment of PTSD
Physical ProximityWhere were students when the crisis occurred (i.e., how close were they to the traumatic event)?
The closer they were (i.e., the more direct their exposure) the greater the risk of psychological trauma.The more physically distant they were, the lower the risk of psychological trauma.
Brock (2006); Brock et al. (in preparation)
44
Initial Assessment of PTSD
Physical ProximityResidents between 110th St. and Canal St.
6.8% report PTSD symptoms.Residents south of Canal St (ground zero)
20% report PTSD symptoms.Those who did not witness the event
5.5% had PTSD symptoms.Those who witnessed the event
10.4% had PTSD symptoms.
Galea et al. (2002)
N
S
45
Initial Assessment of PTSD
Physical Proximity PTSD Reaction Index X Eposure Level
0 2 4 6 8 10 12 14
Out of Vicinity
Absent
At Home
In Neighborhood
On Way Home
In School
On Playground
Reaction Index Score (12 > = Severe PTSD)
Pynoos et al. (1987)
46
Initial Assessment of PTSD
Emotional ProximityPTSD Reation Index Categories X Exposure Level
6%11%
56% 56%
17%22% 19%
28%29%
50%
19%13%
49%
17%
7% 5%
0%
10%
20%
30%
40%
50%
60%
Playground At School Not at School Off Track
Exposure Category
% in
the
Expo
sure
Cat
egor
y
No PTSD Mild PTSD Moderate PTSD Severe PTSD
Source: Pynoos et al. (1987)
47
Initial Assessment of PTSD
Emotional ProximityIndividuals who have/had close relationships with crisis victims should be made crisis intervention treatment priorities.May include having a friend who knew someone killed or injured.
Brock (2006); Brock et al. (in preparation)
48
Initial Assessment of PTSD
Emotional ProximityPTSD and Relationship to Victim X Outcome
(i.e., injury or death)52%
15% 25% 18%12% 11% 9%22% 15% 8%
0%
20%
40%
60%
Person Injured Person Died
Outcome Category
Perc
ent w
ith
PTSD
Parent/Sibling Other Family Friend Other Person No one
Applied Research and Consulting et al. (2002, p. 34)
49
Initial Assessment of PTSD
Personal Vulnerabilities*• Internal vulnerability factors• External vulnerability factors
*Risk factors that increase the probability of psychological trauma and, as such, should result in increased vigilance for psychological trauma warning signs.
Brock (2006); Brock et al. (in preparation)
50
Initial Assessment of PTSDInternal Vulnerability Factors
• Avoidance coping style• Pre-existing mental illness• Poor self regulation of emotion• Low developmental level and poor problem
solving• History of prior psychological trauma• Self-efficacy and external locus of control
Brock (2006); Brock et al. (in preparation)
51
Initial Assessment of PTSD
External Vulnerability Factors• Family resources
Not living with nuclear familyIneffective & uncaring parentingFamily dysfunction (e.g., alcoholism, violence, child maltreatment, mental illness)Parental PTSD/maladaptive coping with the stressorPoverty/financial Stress
• Social resourcesSocial isolation Lack of perceived social support
Brock (2006); Brock et al. (in preparation)
52
Initial Assessment of PTSD
Threat Perceptions*Subjective impressions can be more important that actual crisis exposure.Adult reactions are important influences on student threat perceptions.
* Risk factor that increase the probability of psychological trauma and, as such, should result in increased vigilance for psychological trauma warning signs.
Brock (2006); Brock et al. (in preparation)
53
Initial Assessment of PTSDCrisis Reactions*Severe acute stress reactions predict PTSD. Reactions suggesting the need for an immediate mental health referral
DissociationHyperarousalPersistent re-experiencing of the crisis eventPersistent avoidance of crisis remindersSignificant depressionPsychotic symptoms
*Warning signs that provide concrete indication of psychological trauma
Brock (2006); Brock et al. (in preparation)
54
Initial Assessment of PTSD
Crisis Reactions• Cultural considerations
Other important determinants of crisis reactions in general, and grief in particular, are family, cultural and religious beliefs. Providers of crisis intervention assistance should inform themselves about cultural norms with the assistance of community cultural leaders who best understand local customs.
Lipson, J. G., & Dibble, S. L. (Eds.). (2005). Culture & clinical care. San Francisco: UCSF Nursing Press.
56
Initial Assessment of PTSDMulti-Method & Multi-Source
“Traumatized youths do not generally seek professional assistance, and recruiting school personnel to refer trauma-exposed students to school counselors can also leave many of these students unidentified.”“These findings suggest that a more comprehensive assessment of exposure parameters, associated distress, and impairment in functioning is needed to make informed treatment decisions, especially given the possibility of inaccuracies in child and adolescent reports of the degree of exposure and the great variability in responses to similar traumatic events observed among survivors.”
Saltzman et al. (2001, p. 292)
57
Initial Assessment of PTSD
Primary Evaluation of Psychological TraumaTakes place immediately after the crisisInitial Risk Screening Form
Brock (2006); Brock et al. (in preparation)
58
Initial Assessment of PTSD
Secondary Evaluation of Psychological TraumaBegins as soon as school crisis interventions begin to be provided.Designed to identify those who are actually demonstrating warning signs of psychological trauma and to make more informed school crisis intervention treatment decisions.
Brock (2006); Brock et al. (in preparation)
59
Initial Assessment of PTSD
Secondary Evaluation of Psychological TraumaTypically includes assessment of the following risk factors and warning signs
Crisis exposure (physical and emotional proximity)Personal vulnerabilitiesCrisis reactions
Typically involves the following strategiesUse of parent, teacher, peer, and self-referral procedures/formsAdministering individual and/or group screening measures
Brock (2006); Brock et al. (in preparation)
60
Initial Assessment of PTSD
Secondary Evaluation of Psychological TraumaParent, teacher, and self-referral procedures/forms
Elements of a referral formIdentifying informationPhysical proximityEmotional proximity Vulnerabilities
Personal historyResourcesMental health
Brock (2006); Brock et al. (in preparation)
61
Initial Assessment of PTSD
Secondary Evaluation of Psychological TraumaElements of a referral form (continued)
Crisis ReactionsDissociationHyperarousalRe-experiencingAvoidanceDepressionPsychosis
Dangerous coping efforts (i.e., behaviors that involve any degree of lethality)
Source: Brock (2006)
62
Initial Assessment of PTSDSecondary Evaluation of Psychological Trauma
www.childtrauma.com/ax.html#m5 min.Grd. 4-8Greenwald & Rubin (1999)
Child Report of Posttraumatic Symptoms
www.childtrauma.com/ax.html#m5 min.Grd. 4-8Greenwald & Rubin (1999)
Parent Report of Posttraumatic Symptoms
[email protected] min.8-15 yrs.Foa (2002)Foa et al.
(2001)
Children’s PTSD Symptom Scale
www3.parinc.com20 min.7-16 yrs.Briere(1996)
Trauma Symptom Checklist for Children
AvailabilityAdmin. Time
Age Group
AuthorMeasure
63
Initial Assessment of PTSDSecondary Evaluation of Psychological Trauma
www.mentalhealth.org/publications/allpubs/SMA95-
3022/default.asp
5-10 min.
2-10 yrs.
Saylor (2002)Saylor et al.
(1999)
Pediatric Emotional Distress Scale
www.HarcourtAssessment.com5-20 min.
6-18 yrs.
Saigh (2004)Saigh et al.
(2000)
Children’s PTSD Inventory
[email protected] min.
7 yrs –adult
Pynoos et al. (1998)
Steinberg et al. (n.d.)
UCLA PTSD Reaction Index for DSM-IV (Child, Adolescent, and Parent)
[email protected] min.
8-12 yrs.
Jones et al. (2002)
Child’s Reactions to Traumatic Events Scale
AvailabilityAdminTime
Age Group
AuthorMeasure
64
Initial Assessment of PTSD
Tertiary Evaluation of Psychological TraumaScreening for psychiatric disturbances (e.g., PTSD) typically begins weeks after a crisis event has ended. It is designed to identify that minority of students and/or staff who will require mental health treatment referrals.Typically includes the careful monitoring of crisis reactions/student and staff adjustment as ongoing school crisis intervention assistance is provided.
Brock (2006)
65
Workshop Outline
DSM-TR-IV Diagnostic CriteriaCausesConsequences
CognitiveEmotional and BehavioralAcademic
Initial Assessment (or Screening)Interventions
PreventionAcademicPsychologicalMedical
66
Interventions for PTSD
Prevention of PTSDFoster Internal Resiliency
Promote active (or approach oriented) coping styles.Promote student mental health.Teach students how to better regulate their emotions.Develop problem-solving skills.Promote self-confidence and self-esteem.Promote internal locus of control.Validate the importance of faith and belief systems.Others?
Brock (2006); Brock et al. (in preparation)
67
Interventions for PTSD
Prevention of PTSDFoster External Resiliency
Support families (i.e., provide parent education and appropriate social services).Facilitate peer relationships.Provide access to positive adult role models.Ensure connections with pro-social institutions.Others?
Brock (2006); Brock et al. (in preparation)
68
Interventions for PTSD
Prevention of PTSDKeep Students Safe
Remove students from dangerous or harmful situations.Implement disaster/crisis response procedures (e.g., evacuations, lockdowns, etc.).“The immediate response following a crisis is to ensure safety by removing children and families from continued threat of danger” (Joshi & Lewin, 2004, p. 715).“To begin the healing process, discontinuation of existing stressors is of immediate importance”(Barenbaum et al., 2004, p. 48).
Brock (2006); Brock et al. (in preparation)
69
Interventions for PTSD
Prevention of PTSDAvoid Crisis Scenes, Images, and Reactions of Others
Direct ambulatory students away from the crisis site.Do not allow students to view medical triage.Restrict and/or monitor television viewing.Minimize exposure to the traumatic stress reactions seen among others (especially adults who are in caregiving roles)
Brock (2006); Brock et al. (in preparation)
70
Interventions for PTSD
Academic Interventions1. Use a constructivist approach2. Include discovery of competence 3. Hunter’s Lesson Plan Model 4. Cooperative learning
71
Interventions for PTSD
Academic Interventions: Executive Functioning
Promote Initiation/Focus1. Increase structure 2. Consistent and predictable daily routines3. Short breaks and activities4. External prompting (cues, oral directions)5. Allow time for self-engagement instead of
expecting immediate compliance
72
Interventions for PTSD
Academic Interventions: Executive Functioning (cont.)
Holding = maintain information in working memory until can process and act upon
1. Shorten multi-step directions2. Post the directions on board/in classroom3. Provide visual aides4. Use visualization or “seeing” the information as a
teaching strategy
73
Interventions for PTSDAcademic Interventions: Executive Functioning (cont.)
Inhibition = resistance to act upon first impulse1. Modeling, teaching, and practicing mental routines
encouraging child to stop and thinkStop! Think. Good choice? Bad Choice?
2. Anticipate when behavior is likely to be a problem3. Examining situations/environments to identify antecedent
conditions that will trigger disinhibited behavior – alter those conditions
4. Explicitly inform student of the limits of acceptable behavior5. Provide set routines with written guidelines
74
Interventions for PTSD
Academic Interventions: Executive Functioning (cont.)
Monitoring = ability to check for accuracy1. Model, teach, and practice use of monitoring
routines2. Prompt student if they fail to self-cue3. Provide opportunities for guided practice
75
Interventions for PTSD
Psychological InterventionsGeneral Therapy Issues
Clarifying the facts about the traumatic eventNormalizing reactionsEncouraging expression of feelingsProvide education to the child about experienceEncourage exploration and correction of inaccurate attributions regarding the traumaStress management strategies
76
Interventions for PTSD
Psychological InterventionsEarly InterventionsCognitive Behavioral TherapiesGroups ApproachesOther Treatments
77
Interventions for PTSD
Psychological InterventionsGeneral Immediate Crisis Intervention Issues
1. Cultural differences2. Body language3. Small groups4. Genders5. Appropriate tools6. Frequent breaks7. Develop narrative
78
Interventions for PTSD
Psychological InterventionsRecommended Early Interventions
Minimize crisis exposureEnsure that the child feels safeFacilitate the cognitive masteryStimulate family communication and support
Dyregov & Yule (2006)
79
Interventions for PTSD
Psychological InterventionsQuestionable Early Interventions
Psychological Debriefing (e.g., Critical Incident Stress Debriefing)
No evidence to suggest it prevents PTSDNo evidence to suggest it increases adverse psychological reactionsMay reduce trauma-related symptoms
Cohen (2003); Stallard & Slater (2003)
80
Interventions for PTSDMeta-analysis of single session debriefings.Utilized CISD interventions.Intervention provided within one month of event.
Results: CISD was not found to be effective in lowering the incidence of PTSD.
Van Emmerik et al. (2002)
81
Interventions for PTSDConclusions about CISD and PTSD
May interfere natural processing of a traumatic eventMay inadvertently lead victims to bypass natural supports (i.e., family and friends)May increase awareness to normal reactions of distress and suggest that those reactions warrant professional careGroup debriefings were not effective in lowering the incidence of PTSDIn some cases, debriefing was suggested to be more harmful than good.
Appear to have made those who were acutely psychologically traumatized worse.
82
Interventions for PTSD
Psychosocial InterventionsEmpirically Supported Cognitive-Behavioral Approaches1. Exposure Therapy2. Cognitive Restructuring3. Stress Inoculation Training4. Anxiety Management Training5. Trauma Focused CBT
Dyregrov & Yule (2005), Feeny et al. (2004), NIMH (2007)
83
Interventions for PTSDPsychological Interventions
Empirically Supported Cognitive Behavioral Approaches
Exposure TherapyDesigned to help children confront feared objects, situations, memories, and images associated with the crisis event.Face and gain control of overwhelming fear and distress.
Carr (2004), NIMH (2007)
84
Interventions for PTSDPsychological Interventions
Empirically Supported Cognitive Behavioral Approaches
Exposure TherapyImaginal Exposure
Repeated re-counting of (or imaginal exposure to) the traumatic memory; uses imagery or writing
In Vivo ExposureVisiting the scene of the trauma
Carr (2004), NIMH (2007)
85
Interventions for PTSDPsychological Interventions
Empirically Supported Cognitive Behavioral Approaches
Exposure TherapyInvolves …
VisualizationAnxiety ratingHabituation
Carr (2004), NIMH (2007)
86
Psychological InterventionsCognitive-Behavioral Approaches
“Overall, there is growing evidence that a variety of CBT programs are effective in treating youth with PTSD” … “Practically, this suggests that psychologists treating children with PTSD can use cognitive-behavioral interventions and be on solid ground in using these approaches” (Feeny et al., 2004, p. 473).
Interventions for PTSD
87
Psychological InterventionsCognitive-Behavioral Approaches
“In sum, cognitive behavioral approaches to the treatment of PTSD, anxiety, depression, and other trauma-related symptoms have been quite efficacious with children exposed to various forms of trauma” (Brown & Bobrow, 2004, p. 216).
Interventions for PTSD
88
Interventions for PTSD
Psychological InterventionsGroup Approaches
Group-Delivered Cognitive-Behavioral InterventionsThe effectiveness of group interventions has been proven effective among refugee children. Benefits of a group approach included:
Assisted a large number of students at once.Decreased sense of hopelessness.Normalizes reactions.
Ehntholt et al. (2005)
89
Interventions for PTSD
Psychological InterventionsOther Approaches
Eye Movement Desensitization and Reprocessing (EMDR)
Uses elements of cognitive behavioral and psychodynamic treatmentsEmploys an Eight-Phase treatment approachPrincipals of dual stimulation set this treatment apart: tactile, sound, or eye movement components
Narrative Exposure Therapy
90
Interventions for PTSD
EMDR ProsMore efficient (less total treatment time)Reduces trauma related symptomsComparable to other Cognitive Behavioral Therapies
Suggested to be more effective than Prolonged Exposure
Korn et al. (2002)
91
Interventions for PTSD
EMDR ConsLimited research with childrenNo school-based researchReferral to a trained professional is required
Perkins et al. (2002)
92
Interventions for PTSD
Medical Treatments for PTSDLimited research
Imipramine Without more and better studies documenting good effects and absence of serious side-effects, we urge clinicians to exercise extreme caution in using psycho-pharmacological agents for children, especially as CBT-methods are available to reduce posttraumatic symptoms and PTSD” (Dyregrov & Yule, 2006,p. 181)
93
ReferencesAmerican Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text rev.). Washington, D.C., Author.
Applied Research and Consulting, Columbia University Mailman School of Public Health, & New York Psychiatric Institute. (2002, May 6). Effects of the World Trade Center attack on NYC public school students: Initial report to the New York City Board of Education. New York: New York City Board of Education.
Barenbaum, J., Ruchkin, V., & Schwab-Stone, M. (2004). The psychosocial aspects of children exposed to war: Practice and policy initiatives. Journal of Child Psychology and Psychiatry, 45,41-62.
Berkowitz, S. J. (2003). Children exposed to community violence: The rationale for early intervention. Clinical Child and Family Psychology Review, 6, 293-302
Brock, S. E. (2006, July). Crisis intervention and recovery: The roles of school-based mental health professionals. Bethesda, MD: National Association of School Psychologists.
94
Selected ReferencesBrock, S. E. (2006). Crisis intervention and recovery: The roles of
school-based mental health professionals. (Available from National Association of School Psychologists, 4340 East West Highway, Suite 402, Bethesda, MD 20814).
Brock, S. E., Nickerson, A. B., Reeves, M. A., Jimerson, S. R., Lieberman, R. A., & Feinberg, T. (in preparation). School crisisprevention and intervention Bethesda, MD: NASP.
Brown, E. J., & Bobrow, A. L. (2004). School entry after a community-wide trauma: Challenges and lessons learned from September 11th,2001. Clinical Child and Family Psychology Review, 7, 211-221;
Buka, S. L., Stichick, T. L., Birdthistle, I., & Earls, F. J. (2001). Youth exposure to violence: Prevalence, risks, and consequences. American Journal of Orthopsychiatry, 71, 298-310.
Carr, A. (2004). Interventions for post-traumatic stress disorder in children and adolescents. Pediatric Rehabilitation, 7, 231-244.
Cook-Cottone, C. (2004). Childhood posttraumatic stress disorder: Diagnosis, treatment, and school reintegration. School Psychology Review, 33, 127-139.
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Selected ReferencesCostello, E. J., Erkanli, A., Fairbank, J. A., & Angold, A. (2002). The
prevalence of potentially traumatic events in childhood and adolescence. Journal of Traumatic Stress, 15, 99-112.
Dulmus, C. N. (2003). Approaches to preventing the psychological impact of community violence exposure on children. Crisis Intervention, 6, 185-201.
Dyregrov, A., & Yule, W. (2006). A review of PTSD in children. Child and Adolescent Mental Health, 11, 176-184.
Ehntholt, A. K, Smith, A. P, & Yule, W. (2005). School-based cognitive-behavioural therapy group intervention for refugee children who have experienced war-related trauma. Clinical Child Psychology and Psychiatry, 10, 235-250.
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The Identification, Assessment, and Treatment of PTSD at School
Stephen E. Brock, Ph.D., NCSPCalifornia State University, [email protected]
Melissa A. Reeves, Ph.D., NCSPWinthrop University, Rock Hill, [email protected]
National Association of School Psychologists (NSPA) & American Healthcare Institute (AHI) Critical Skills and Issues in School Psychology 2008 Summer Conference, July 30, 2008, Las Vegas, NV